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Chapter 31
Upper-Extremity Amputation and
Prosthetic Rehabilitation
Click to see UE Amputation Protocol

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Amputation is an ancient surgical procedure used to save

life or to preserve body parts. It can be a devastating loss,
particularly when it involves the dominant hand or both
upper extremities. Over 12,000 persons experience a major
upper-extremity or hand amputation in the United States
annually (1). Upper-extremity amputations constitute
less than 20% of all amputations performed in the United
States. Trauma is the number one cause of transhumeral
to fingertip amputations (2,3). More than 90% of
upper-extremity limb losses result from accidents, usually
industrial accidents. This is in contrast to lowerextremity amputations, which usually result from systemic
disease, such as diabetes mellitus or peripheral vascular
disease.
Lower-extremity amputation occurs typically in the
older individual with chronic medical problems, usually
during the fifth through seventh decades, while upperextremity loss occurs primarily in healthy young men
between the ages 20 and 40 years (14). Because of the
youth and good health of the upper-limb amputee, these
individuals comprise a larger percentage of the disabled
community than the 20% incidence of upper-extremity
amputation would suggest. The person with upperextremity loss will live longer than the lower-extremity
counterpart, imposing heavy costs on the individual and
society as a whole.
Amputation is not merely the loss of a body part.
Limb loss impacts a persons body image, self-perception,
physical identity, career, and psychosocial functioning. In

M. Catherine Spires
Linda Miner
Miles O. Colwell

some cultures, amputation is performed as a punishment

for criminal behavior, consequently carrying a powerful
negative social stigma regardless of the etiology. Though
less dramatic in American culture, amputees frequently
experience negative interpersonal reactions from others
and are often isolated from other people.
Rehabilitation is not simply a matter of replacing
missing body parts. Because amputation impacts the
person at all levels of psychosocial and physical functioning, successful prosthetic restoration and rehabilitation
must address the individuals physical and psychosocial
well-being. If these areas are effectively addressed, the individual who has had an upper-extremity amputation will
return to a productive and satisfying life.
The principles of upper-extremity prosthetic restoration and rehabilitation differ from those of lower-limb
prosthetic restoration. While an upper-extremity prosthesis,
like the lower-limb prosthesis, replaces some of the lost
gross movements, modern technology does not approach
the sophistication of the intact human upper extremity
and hand. The upper extremitys specialized functions of
precise fine-motor control and the multimodality sensation,
including proprioceptive feedback, have yet to be achieved.
Since lower-extremity function is less complex, prosthetic
design focuses primarily on gross motor activities, such as
walking and standing.
One of the earliest known upper-limb prostheses
dates back to the second Punic Wars of the second century
BC (218201 BC). Marcus Sergius, a Roman general who

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lost his arm in battle, held his shield using an iron prosthetic hand during combat (per account by Pliny).
During the following centuries, a variety of devices
were used to replace the upper extremity. By the sixteenth
century, Ambroise Par, a French military surgeon,
designed the forerunner of todays modern upperextremity prosthesis. His design allowed the amputee to
passively position the hand and lock it into place. Though
a locksmith could duplicate his design, it was expensive. As
a result, Pars design was only available to the wealthy.
The commoner managed without a prosthesis or used a
leather socket with a stationary hook.
In the nineteenth century, Peter Baliff, a dentist,
designed the first body-powered prosthesis, which used
proximal muscle force to produce a weak prosthetic grasp
and release. Though originally designed for the belowelbow (BE) amputee, it was soon modified for the aboveelbow (AE) amputee using a chest lever to control the AE
prosthesis. During this same period, Comte de Beaufort
developed the double spring hook, the forerunner of
todays hook terminal device (TD).
The twentieth century brought major changes in
upper-extremity prosthetics. The injuries during the world
wars, as well as the thalidomide tragedy of the late 1950s,
accelerated the pace of prosthetic technology and research.
After decades of research, the myoelectric prostheses
became a reality. These prostheses remain the most successful externally powered prostheses ever developed.
Though modern prostheses are not as elegant and
complex as the human upper extremity and hand, the
current generation of upper-extremity amputees lead full
and productive lives because of the advances of prosthetic
technology and research (e.g., improved fitting and suspension techniques, new lightweight durable materials, and
more sophisticated body-powered and externally powered
components).
Prosthetic technology changes rapidly. It is impossible for a text of this type to keep pace with the rapid
changes and availability of new technology. However, the
basic principles of prosthetic restoration and rehabilitation
after upper-extremity amputation change little. This
chapter focuses on these basic principles. If the physiatrist
and other rehabilitation team members follow these fundamental principles, the upper-extremity amputee will
achieve the optimal prosthetic restoration and function
possible with todays advanced technology. As in any field
of medicine, this text cannot substitute for the clinicians
need to study ongoing research and to learn from ones
patients and their experience.
The basic surgical principles of amputation are
reviewed. Obviously, a trained surgeon is the appropriate
professional to perform amputations. However, the physiatrist, and other rehabilitation team members, need to
understand the surgical principles of limb amputation.
The informed rehabilitation specialist is able to discuss the
prosthetic and rehabilitation implications of various surgi-

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Part III

Therapeutic Interventions

cal procedures. Collaboration between the surgeon, physiatrist, patient, prosthetist, therapists, and other rehabilitation
team members guarantees that the patient receives optimal
surgical and rehabilitation care. This chapter is written to
assist the surgical and rehabilitation team in their efforts to
collaborate and maximize the patients functional outcome.
An overview of surgical principles is presented first, followed by a presentation of prosthetic restoration and
rehabilitation.

SURGICAL PRINCIPLES
General Principles
Upper-extremity amputation is performed infrequently. As
a result, few surgeons have the opportunity to work with
upper-extremity amputees. Surgeons often consult with
physiatrists to advise them regarding the prosthetic and
rehabilitation implications of surgical decisions. Collaboration between the surgical and rehabilitation team guarantees that the patient will experience the best surgical and
functional outcome.
Many consider amputation a surgical failure: The
limb could not be saved. However, amputation does not
equate to failure. New surgical techniques and prosthetic
technology make it possible for amputation to be a part of
an overall plan of upper-extremity reconstruction, not
simply a surgery of last resort. Obviously, if amputation is
not necessary, it should not be done. But when it is the best
option for the patient, amputation can be the basis of
upper-limb reconstruction and the first step in upperextremity rehabilitation. Approaching the amputation as a
reconstructive procedure facilitates achieving a painless,
cosmetic, and functional limb. This reconstructive
approach, coupled with a patient-oriented approach,
focuses the medical teams efforts on achieving a positive
functional outcome as defined by the individuals needs.
The goal of successful rehabilitation is an individual
who can assume autonomy and responsibility for all
aspects of his or her life. The patients attitude, as well as
the attitude of the surgical and rehabilitation team, is key
to achieving this goal. The patient needs to know that a
multidisciplinary coordinated effort is being made to optimize upper-extremity repair and reconstruction.
In general, there are two types of amputation. The
open amputation, also called a guillotine amputation, is indicated when severe infection or sepsis is present. The amputation wound is not closed; treatment is directed at
resolution of the infection. Definitive closure is performed
once the infection has resolved. The second type, the closed
or definitive amputation, involves primary closure of the
amputation site. Definitive closure is indicated if the limb
is not infected and wound healing is a reasonable
expectation.
Typically, the surgical incision is best placed in a
transverse position, with anterior and posterior skin flaps of

equal length. With this technique, the surgical scar will be

at the end of the residual limb where it will not be in
contact with the prosthetic socket. Scar formation on the
posterior or anterior surface of the residual limb causes
pain from the mechanical pressure of the prosthetic socket.
Like other amputations, dog ears, soft-tissue projections
from the medial or lateral end of the surgical incision, are
undesirable.
Often plastic procedures, such as placement of skin
grafts or flaps, are required to preserve length and function. The choice of the type of graft or flap depends on
the specific surgical needs and available viable tissue.
Length is a crucial issue for amputations about the shoulder and below the elbow. Split-thickness skin grafts can
effectively preserve needed length (5).
Bone section should be a clean cut across the level,
with rough surfaces smoothed. The shaping of the bone
must be compatible with future prosthetic use and socket
fitting. In the case of disarticulation, cartilage surfaces are
preserved. The articular cartilage provides a weightbearing surface, and in children, prevents bony overgrowth
at the distal end of the residual limb.
The muscle and tendons are divided distal to the site
of bone sectioning. Except for in digits, a myoplasty is typically performed. Muscles, at their normal resting length,
are sewn to their antagonists to secure them together. A
myodesis, which secures the tendon and muscle to the
bone, is another option. If the distal musculature and
tendons are not secured, they will retract proximally. If this
occurs, the patient is not able to use these muscles to
control the residual limb or use these muscles for future
myoelectric control sites.
Neuromas are an inevitable consequence of surgical
sectioning of a peripheral nerve. During amputation, nerve
division must be done carefully. The involved nerves
should be isolated, gentle traction should be applied, and
then the nerves sharply sectioned 2 to 4 cm proximal to the
osteotomy site (4). Once the nerve is sectioned, traction is
relieved, allowing the nerve to retract into proximal tissues.
This technique allows the neuroma to develop deep in soft
tissues, where irritation from scarring or pressure is less
likely to occur. Meticulous surgical techniques will ensure
that neuromas form away from areas of potential irritation
caused by the prosthetic socket or components. Neuromas
that develop in flexion crease regions trigger acute and
chronic neurogenic pain.
Lastly, closure should be meticulous. Closure
should be done in such a way as to avoid the development
of adherent scar, redundant tissue, or an irregularly shaped
residual limb. Especially in the AE amputee, redundant
tissue should be avoided. Excess soft tissue makes
prosthetic socket fitting and prosthetic control difficult.
Characteristics of a residual upper extremity suitable
for prosthetic fitting include a cylindrical limb with a wellplaced scar, good skin coverage, adequate soft-tissue
coverage, and intact sensation. Ideally, the patient should

Chapter 31

be pain free. If this is not feasible, pain should be sufficiently controlled so that the person is able to tolerate the
prosthesis.
In summary, the goals of surgical amputation are to
1) preserve functional length of the extremity, 2) preserve
useful sensation, 3) prevent symptomatic neuromas or pain
syndromes, 4) prevent adjacent joint contractures, 5) minimize recovery time, and 6) achieve early prosthetic fitting
to facilitate return to work, activities of daily living (ADLs),
recreation, and socialization (6).
Lastly, the development of sophisticated microsurgery techniques makes upper-limb replantation and
reconstruction feasible. In some situations of traumatic
limb loss, replantation is an option; replantation of the
proximal part of the arm is less successful than BE replantation. Kleinert and others (79) suggested that the lower
success rate is secondary to warm ischemia affecting a
greater muscle mass. Additionally, reinnervation must
occur over a much longer segment in proximal replantation. If replantation is performed, it is most successful in
the very young patient whose injuries do not preclude
skeletal and neurovascular reattachment (10). Functional
neurologic recovery is best in children. Since replantation
is not without risk, the patients overall status, the duration
of limb ischemia, and the likelihood of metabolic replantation toxemia must be considered (11).

Selection of Amputation Site

The level of amputation is dictated by the site of trauma,
tumor, or pathology. Though there is limited control over
the etiology and its effects, the surgeon may have some
choice of the amputation level. The surgeon must choose
the most distal amputation site that will allow satisfactory
healing, prosthetic restoration, and rehabilitation. Judicious
selection of the surgical level, implementation of appropriate amputation techniques, and careful tissue management
will have a long-lasting positive influence on future prosthetic restoration, rehabilitation, and lifestyle.
Anatomically, there are many levels of amputation,
including partial hand, wrist disarticulation (WD), BE (also
called a transradial) amputation, AE (or transhumeral)
amputation, shoulder disarticulation (SD), and forequarter
(FQ) amputation (Fig. 31-1).

Partial Hand Amputations

The hand is a very complex and intricate element of the
human upper extremity. Object manipulation, precision
pinch, and power grasp are the primary functions of the
hand. Precision pinch requires, at minimum, two opposing
digits. Not only must the digits be capable of motion, but
they must also have functional sensation. Pinch can be subdivided into three basic types: tip-to-tip pinch, three-digit
pinch, and lateral pinch. In the normal hand, the thumb
opposing the index and long fingers, also called the radial
tripod, creates a precise pinch.
Power grasp is the action of holding something

Upper-Extremity Amputation and Prosthetic Rehabilitation

551

Figure 31-1. The various anatomic levels of

an upper-extremity amputation.

Upper/extremity amputations

Level and loss

Forequarter amputation (FQ)

Shoulder disarticulation (SD)

030%

3050%

5090%

90100%

Very short above elbow (AE)

Short above elbow (AE)

Standard above elbow (AE)

Long above elbow (AE)

Elbow disarticulation (ED)

035%

3555%

5590%

90100%

Very short below elbow (BE)

Short below elbow (BE)

Long below elbow (BE)

Wrist disarticulation (WD)

Carpal disarticulation (CD)
Transmetacarpal

securely against the palm of the hand. The prerequisites

for a power grasp are sufficient hand width, at least three
metacarpal heads, and mobile metacarpophalangeal
(MCP) and interphalangeal (IP) joints. The thumb and
index finger facilitate control and strengthen grasp, but the
middle, ring, and small fingers are also considered key elements. The fifth finger, or so-called small digit, superficially
seems unimportant but it prevents the object slipping away
from the palm by creating an ulnar cup. It is essential for
gripping tools. The index finger provides 50% of the stability and 20% of the strength of the power grasp (6).
The most common type of upper-extremity amputation is the fingertip amputation. Some propose grafting
while others propose conservative treatment if the amputation is distal to the distal interphalangeal (DIP) joint.

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Therapeutic Interventions

Primary suture or closure by secondary intention is acceptable and prevents the morbidity associated with skin grafting. However with bone exposure, one must shorten the
bone or cover using a flap (12). If the amputation is
through the IP joint, the condyles are usually shaped to
improve cosmesis. Of adults with a fingertip injury and
pulp loss, 30% to 50% have cold intolerance or aberration
of sensibility regardless of the technique used (6).
The flexors and extensors of the hand are treated
differently than other upper-extremity muscles. Generally,
myodesis or myoplasty is advised when sectioning muscles
and tendons. In the hand, however, the flexor and extensor
tendons are divided and allowed to retract. These tendons
are not sewn together. This prevents the development of a
finger flexor condition, known as quadriga. Amputation

through the middle phalanx distal to the flexor digitorum

sublimis (FDS) preserves functional flexion of the middle
phalanx. However, if the FDS insertion cannot be preserved, amputation through the proximal interphalangeal
(PIP) joint is usually performed.
With loss of the long or ring finger at the level of the
MCP joint, or the presence of a very short digital
residuum, small objects can fall out of the hand. If the
individual cannot voluntarily flex the digital remnant, or
the amputation is at the level of the MCP joint, a ray deletion or transposition may increase function and improve
cosmesis. If transposition is not possible, then deletion with
closure of the central defect creates a functional and cosmetic hand.
Ray amputations are often done electively to minimize disability from a previous injury to a digit. This is
usually not done at the time of trauma because the patient
needs to determine if a digit stump is useful or not. If the
index finger is very short and cannot be used for pinch, the
remnant may interfere with the individual pinching
between the thumb and the middle finger. Since the index
finger provides stability to the power grip, significant effort
is made to preserve the length and sensation of the index
finger, particularly in manual laborers. Resection of the
index ray can reduce grip strength by 20%, but can
markedly improve cosmesis (13).
Though the underlying pathology primarily dictates
the level of amputation, the patients lifestyle and occupation also impact this decision. The jeweler who has lost an
index finger at the MCP joint requires preservation of a
precise pinch, or if not possible, hand reconstruction to
restore precise pinch. This may require resection of the
index ray to prevent it from mechanically interfering with
opposition of the thumb and long finger. However, digit
loss at the same level in a construction worker dictates a
different approach. In this case, preservation of the ray of
the index finger preserves power grip by preserving palmar
width and stability.
The thumb provides 40% to 50% of hand function
and 30% of upper-extremity function. It is important for
power and precision grasp. Length, sensation, and stability
of the thumb for opposition are high priorities. When indicated, skin grafting can preserve length, allowing sufficient
residuum for pinch and grip. The precise length needed to
preserve thumb function is controversial, but a minimum
length of 2 cm has been proposed (14). Distraction, bone
grafting, and phalangealization of the first web space are
options available to lengthen the thumb remnant. It is
important to remember that the replanted thumb, as well
as the reconstructed thumb, will not necessarily have
normal function (15). If pollicization is required, the index
finger is the best digit to use (16).
For multiple-digit amputation, it is important to
remember that rudimentary grasp requires a cleft between
two opposing poles that are rotated to be opposite to each
other or can be adducted together (parallel adduction).

Chapter 31

Wrist Disarticulation
In the past, WD gained popularity because it preserves the
articular surface of the distal radioulnar joint and maximal
forearm supination and pronation. WD provides a tolerant
end-bearing surface. The shape of the distal end is conducive to a self-suspending socket, though additional straps
may be required for heavy work (17).
WD has disadvantages, however. The broad
distal socket required to accommodate the residual styloid
processes makes fabricating an aesthetically acceptable
prosthesis difficult. The styloid prominences can be
reduced at the time of disarticulation but some of the
advantage of the wide distal residual limb for a selfsuspending socket is lost. The addition of a prosthetic
wrist unit, which allows for an interchange of TDs such
as hands and hooks on the prosthesis, can make the artificial limb longer than the intact arm. This is more obvious
with a prosthetic hand than with a hook. Extra length
reduces cosmesis and interferes with midline hand to
mouth activities. Consequently, the selection of wrist units
and TDs is limited. Additionally, if a persons goal is to
use a myoelectric prosthesis, disarticulation is a poor choice
because myoelectric units also add length to the prosthetic
forearm. A long transradial amputation would be a better
choice if the patient is a candidate for a myoelectric
prosthesis.

Transradial or Below-Elbow Amputation

For transradial or BE amputation, the forearm is divided
into three lengths: the distal, middle, and proximal thirds.
It is important to conserve all possible length of the limb
(18), with a minimum of 10 cm below the lateral epicondyle of the humerus being preferred. Individuals
with a very short forearm remnant have difficulty tolerating the weight of a BE prosthesis. However, it is worthwhile to save even 4 to 5 cm of the limb if the brachialis is
intact and the biceps brachii can be divided and transferred to the ulna, to add control and facilitate prosthetic
fitting (19). The radius and ulna are typically sectioned at
the same length. The elbow joint should be saved whenever feasible. Natural flexion and extension are preserved
and one less prosthetic joint is required. Many authors
contend that preservation of the elbow cannot be
overemphasized (1).
A longer residuum provides a greater lever arm and
consequently greater forearm strength and power. Greater
forearm rotation is preserved. An amputation at 2 cm or
more proximal to the wrist allows more room for prosthetic components (1,20). At this level, approximately 70%
to 80% of natural pronation and supination are preserved.
As the forearm length decreases to 60% or shorter, there is
rapid loss of rotation until no natural pronation or supination is preserved. Without natural forearm supination and
pronation, a method of rotating the forearm must be
incorporated in the prosthesis.

Upper-Extremity Amputation and Prosthetic Rehabilitation

553

Elbow Disarticulation
Elbow disarticulation (ED) has several advantages. Preservation of the humeral condylar flares facilitates prosthetic
suspension. Because the humeral condyles fit snugly into
the prosthetic socket, humeral rotation is efficiently transmitted to the prosthesis. ED provides a longer lever arm
than an AE amputation does. Additionally, the distal end is
pressure tolerant since the articular cartilage is preserved.
Cosmesis is the primary disadvantage of ED. The
distal end of the prosthesis is bulky. Fewer prosthetic
elbows are available. At this level, outside locking elbow
hinges are required but they can damage clothing and
reduce cosmesis. Myoelectric elbow units, such as the Utah
arm, also create an abnormally long prosthetic arm. To
avoid this length differential, it is possible to fit the patient
with a hybrid prosthesis fabricated with both bodypowered and electronic components.

Transhumeral Amputation
Amputation through the humerus can be done at several
levels. The transcondylar amputation, like ED, preserves
the condylar flares which can transmit humeral rotation to
the prosthesis. Like ED, an external hinge elbow joint is
required, since other elbow units make the prosthetic limb
abnormally long. The remaining humeral condyles require
a socket with a wide distal end, detracting from the overall
appearance of the prosthesis.
A residual limb that is at least 10 cm long, measuring
from the axillary fold, is preferred according to many
sources. The greater the upper-limb loss, the less humeral
rotation is preserved. Designing the prosthesis with an
internal locking prosthetic elbow joint with a turntable for
internal and external rotation (21) offsets this loss to some
degree.

Shoulder Disarticulation and Forequarter Amputation

Amputations at this level are uncommon. Tumor is the
primary cause (22), while major trauma is the second most
frequent cause. Less than 3% of traumatic upper-extremity
amputations occur at this level (23). Traumatic amputation
at this level is frequently secondary to avulsion forces.
Congenital deficiency occurs infrequently at this
level. Like congenital deficiency at other levels, these limbs
rarely need revision. Congenital limb absence often
involves the additional problem of bony malformations
and vestiges of missing portions of the limb; therefore,
prosthetic fitting is often more challenging. A full
understanding of the anatomy and function of the congenitally deficient limb is key for proper prosthesis selection
and fitting, especially if surgical revision is being
considered.
Cosmesis is a major problem (Fig. 31-2). If the
scapula can be retained, disfigurement is less than that
with a FQ limb loss. Though amputation through the surgical neck of the humerus is functionally equivalent to SD,
retention of the surgical neck preserves shoulder fullness,

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Therapeutic Interventions

Figure 31-2. Forequarter amputation results in the loss of

the normal shoulder contour and profile.

width, and contours. Not only is this aesthetically more

pleasing, but also the shoulder contours provide a more
stable purchase for the prosthetic socket. Additionally, the
shoulder contour significantly affects the fit of clothing.
This is particularly important for womens clothing, such as
bras and other undergarments. The contour and symmetry
of the female breast are relatively preserved because the
pectoralis major insertion is not disrupted as with SD.
Lastly, if the deltoid remains, it potentially can be used as
a site for myoelectric control.
At this level, the upper-extremity residuum provides
minimal function. The more proximal an amputation is, the
less functional are the available prostheses. Clinically, it is
observed that the more proximal the upper-extremity
amputation is, the higher the prosthetic rejection rate is.
Clinical experience suggests that externally powered prostheses are rejected less frequently than body-powered prostheses. The externally powered hand is more cosmetic and
more functional than the mechanical hand or hook (24,25).
However, these prostheses are heavy. Because these prostheses are expensive, many funding agencies will not finance an
externally powered prostheses at this level of amputation.

Juvenile Amputees
Though the surgical principles of pediatric amputation are
similar to those for the adult, there are two major distinctions: A disarticulation is preferred to a transdiaphyseal
section and more heroic efforts are indicated to conserve
length (26). In children, epiphyseal preservation is important. The growth potential of the distal epiphyses is greater
than that of the proximal radial and ulnar epiphyses, while

in the humerus, the proximal epiphysis has greater growth

potential.
Disarticulation allows for undisturbed epiphyseal
bone growth, preserving longitudinal growth. Disarticulation also prevents the development of bony overgrowth at
the terminal bone. Since bony prominences (e.g., condyles)
become less prominent with age, disarticulation does not
present the same cosmetic problems that are seen in adults.
In children, bony overgrowth at the site of a traumatic amputation is the most common postamputation
complication. Occurring in about 10% to 30% of pediatric metaphyseal or diaphyseal transections, bony overgrowth is most common in children less than 12 years old
(27). Disarticulation prevents this complication.
The earliest sign of bony overgrowth is the development of an adventitious bursa between the distal end of
the transected bone and the soft tissues. Typically an
advancing bony spike develops, irritating the bursa and
local tissues. Not only pain develops, but also local infection can occur. Terminal bone overgrowth occurs most
often after humeral transection, followed by fibular, tibial,
and femoral transections (27,28).
Studies have shown that bony overgrowth is additive
appositional bone growth from the distal end of the transected bone. Epiphysiodesis does not control the problem
since the bony overgrowth is not the result of epiphyseal
growth. In fact, epiphysiodesis will unnecessarily shorten
the residual limb, potentially causing further functional and
cosmetic loss. Interestingly, bony overgrowth typically stops
with skeletal maturity (29).
Bony overgrowth occurs primarily in children who
have had a surgical or traumatic amputation. Children
with a congenitally deficient limb, particularly those with
amniotic band syndrome (30,31), may develop bony overgrowth. This problem is also seen in adults whose amputations are secondary to an electrical injury (32,33).
If prosthetic modification cannot control the problems associated with bony overgrowth, surgical resection
remains the most effective option (34). Resection is
required in about 10% of children (34).

OVERVIEW OF PROSTHETICS FOR

THE UPPER EXTREMITY
Prostheses can be categorized in many ways: exoskeletal
versus endoskeletal design, passive versus active, bodypowered versus externally powered, and by anatomic level.
Prostheses can also be identified by the stage of prosthetic
restoration and rehabilitation.
The prosthesis with a rigid external structure is
called an exoskeletal prosthesis. This type of prosthesis is more
durable than the endoskeletal prosthesis, which has a rigid
internal structure but a soft exterior. The hard external
layer of the exoskeletal prosthesis allows this prosthesis to
withstand contact with hard or sharp surfaces. The

Chapter 31

Figure-of-eight harness
with O ring
Hook TD
Triceps
cuff

Control cable
Socket
Cable housing

Figure 31-3. Illustration of a typical body-powered, or

conventional, cable-controlled below-elbow
prosthesis with a hook terminal device (TD).

endoskeletal prosthesis has a soft removable outer cover,

which allows easy access to the prosthetic components.
Though endoskeletal designs often weigh less, exoskeletal
prostheses are typically prescribed because of superior
durability.
Some prostheses provide no active function, passively
replacing the missing body part. The appearance resembles the missing limb. These prostheses are chosen for
cosmesis and their relative light weight. Highly sophisticated and nearly perfect anatomic replicas of the missing
limb are available but are very expensive.
Prostheses are also classified by power source, that is,
body-powered versus externally powered prostheses. The
body-powered prosthesis uses a system of straps and cables
to transfer energy of one body part to the prosthesis to
perform a specific motion (Fig. 31-3). For example, the AE
amputee uses scapular and humeral motion to operate a
prosthetic elbow and hand. Externally powered systems
rely on an external source of energy to operate the prosthesis. The most frequently used externally powered prosthesis employs the myoelectric control system, but other
systems exist, including electric switch controls. Myoelectric
prostheses use the electrical potential of a muscle to voluntarily operate components of the prosthesis, for example,
to open and close a prosthetic hand (Fig. 31-4).
Prostheses are also identified by the stage of rehabilitation: the temporary and the definitive prosthesis. The
temporary prosthesis, also called a preparatory or provisional
prosthesis, is used while the residual limb volume is stabilizing and the individual is learning how to use a prosthesis.
This period also allows the amputee to determine which
prosthetic components and options are most appropriate.
A preparatory prosthesis can be very simple. For example,
materials used to make the temporary socket can range
from casting materials to sophisticated thermoplastics.
Though the provisional or preparatory prosthesis is made
with the same attention to fit and function as the definitive
prosthesis, the materials of the temporary prosthesis are

Upper-Extremity Amputation and Prosthetic Rehabilitation

555

Myoelectric or
powered hand

Patients can be fitted while still in the operating

room or fitted early (i.e., within the first 2 weeks) after
amputation. The techniques of immediate or early fitting
remain underutilized, even though studies of both techniques have demonstrated high acceptance rates without
jeopardizing wound healing (3638). Early fitting appears
to be the single most important variable predicting successful prosthetic use.

Motor
Battery
EMG amplifier
Dorsal electrode

Figure 31-4. A typical myoelectrically controlled belowelbow prosthesis with a hand terminal device.
EMG = electromyograph.

not as durable as those of the definitive prosthesis. The

preparatory prosthesis is modified periodically to meet the
amputees advancing skill and to accommodate changes in
the residual limb volume and shape. At this phase of rehabilitation, the final design of the prosthesis is still evolving.
The definitive prosthesis is the final or permanent
prosthesis prescribed and fabricated for the individual. It is
prescribed after the residual limb volume has stabilized
and when the patient is experienced using a prosthesis and
the patient and the rehabilitation team have determined
the most appropriate prosthetic design.

The Principle of Early Prosthetic Fitting

The most important development in the last 15 years of
upper-extremity prosthetics is the realization that upperextremity amputees need to be fitted for a prosthesis early.
Malone et al (35) found that patients fitted within 30 days
of upper-extremity amputation, sometimes called
Malones golden period, demonstrate the greatest success
in prosthetic acceptance and use. Previous to these observations, most patients were fitted with an upper-extremity
prosthesis 3 to 6 months after surgery, or even later. The
rejection rate was as high as 50%. Fitting a prosthesis
within 4 weeks of upper-extremity amputation dramatically improves the long-term outcome. Some (36) centers
report success rates as high as 90%.
Early prosthetic fitting preserves bimanual upperextremity patterns, increasing prosthetic acceptance and
use. Minimizing the time period between loss of bilateral
upper-extremity activity and the return of bilateral function through prosthetic restoration maximizes success. If
prosthetic fitting is delayed, patients quickly learn to be
one handed and forfeit the use of a prosthesis. They do
activities with one hand or expect others to perform twohanded activities for them. Some will avoid bimanual
activities alltogether. The goal of independence is
jeopardized.

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Preparatory Prostheses
The immediate postoperative prosthesis fitting technique is available,
but it is used infrequently. While still in the operating
room, the patient is fitted with an immediate postoperative
prosthesis made of a rigid dressing with minimal, but functional prosthetic components attached. The socket can be
applied once the surgical incision is closed. Initially, the
incision is dressed with a light layer of bandages, and
plaster or fiberglass is used to form a socket on the
patients residual limb. The immediate postoperative prosthesis functions as the final wound dressing.
Immediate postoperative fitting has many advantages, including controlling postoperative edema and pain.
Reducing postoperative edema minimizes postoperative
pain and phantom pain. The immediate postoperative
prosthesis conditions and shapes the residual limb, preparing it for future prosthetic fitting. Additionally, the immediate postoperative prosthesis allows the occupational
therapist (OT) to begin training almost immediately. It is
important that prosthetic training does not begin before
the surgeon agrees. In some cases, the surgeon may allow
the OT to begin training within the first 24 hours of
surgery, whereas others prefer waiting several days. As a
result, the amputee experiences the immediate usefulness
of the residual limb and the prosthesis.
While immediate postoperative fitting sounds ideal, it
requires an experienced, multidisciplinary, surgical and
prosthetic rehabilitation team, available to fit the prosthesis
in the operating or recovery room and to ensure that the
fit is correct to prevent tissue damage and risk further limb
loss. Most amputations are the result of trauma, however,
and there is limited time to assemble an experienced multidisciplinary team.
Early fitting of a temporary prosthesis is more
common than the immediate fitting approach. Once
sutures are removed, about 1 to 2 weeks after surgery,
fitting is begun. Though early fitting occurs during
Malones golden period, some (36) question whether use of
the early fitting technique results in as much acceptance as
use of the immediate fitting approach. However, many
investigators (35,3741) found no appreciable difference
between the success rate of prosthetic use between the two
prosthetic fitting techniques.
Many of the same advantages of immediate postoperative fitting are also seen with early prosthetic fitting.
Bimanual activities are preserved and prosthetic acceptance is high. However, the early fitting approach has addi-

tional advantages, including allowing a longer time for the

incised tissues to heal and allowing the prosthetist more
time to design and fabricate an individualized prosthesis
and use a greater variety of prosthetic components.
The bilateral upper-extremity amputee must receive
a prosthesis early. Without a prosthesis, the amputee is
dependent in virtually all aspects of everyday life. The
earlier a prosthesis is issued, the earlier training in hygiene,
feeding, and self-care can begin. Immediate or early fitting
helps to decrease dependency and reduces some of the
negative psychological and social impact of bilateral amputation. Though for somewhat different reasons, both the
unilateral and the bilateral upper-extremity amputee
should be fit early.
The preparatory or provisional prosthesis may be a
body-powered, myoelectrically controlled, or a combination or hybrid system. This stage of wearing the preparatory prosthesis is a distinct step in prosthetic restoration
and rehabilitation; it involves an evaluation to determine
the most appropriate prosthetic design for the individual.
During this period, the amputee test drives the various
prosthetic designs and develops realistic expectations about
what a prosthesis can and cannot do. The individual experiences firsthand the advantages and disadvantages of
various sockets, suspension systems, elbow and wrist units,
hands, and other terminal devices. Unfortunately, some
funding agencies do not finance a temporary prosthesis
and will only pay for a permanent prosthesis. As a result,
the amputees financial situation may not allow for an evaluation of various prosthetic designs.

Definitive Prostheses
The final or definitive prosthesis represents the culmination
of all the experience and information gained during the
preparatory phase. The definitive prosthesis is the permanent one, the prosthesis the person is going to live with
(Fig. 31-5). Test driving various provisional designs ensures
that no major oversights occur in the design of the permanent prosthesis. Like the provisional prosthesis, the definitive prosthesis can be body powered, myoelectric, or a
hybrid of both. The permanent prosthesis, which must
withstand all types of activities over the long term, is constructed with more durable materials than is the provisional prosthesis.

Upper-Extremity Prosthetic Control Systems

The body-powered prosthesis, also called a mechanical prosthesis, is the conventional upper-extremity prosthesis. Estimates indicate that 90% of upper-extremity amputees who
use a prosthesis use a body-powered system at least part
time. Amputees prefer this system because it is relatively
inexpensive, durable, reliable, and functional. This system
provides some sensory feedback via the cables and harness
control systems (42). Many prefer the speed of operation
and accuracy of body-powered prostheses. Because they do
not require external sources of power, there are no batter-

Chapter 31

ies to recharge or replace. However, many do not like the

appearance of body-powered prostheses. In general, they
are less aesthetic and do not have the high-tech appeal
of the myoelectric system. A body-powered prosthesis has
a weaker grip than the myoelectric one, but it is more
durable for manual work such as lifting (4345).
The myoelectric system is the externally powered
system of choice and is the preference of many amputees.
It harnesses the electrical potential of a contracting muscle
to operate the prosthesis (Fig. 31-6). These prostheses
require minimal proximal muscle control and can be used
in all planes of motion (e.g., overhead reaching). Compared to body-powered prostheses, myoelectric prostheses
provide a stronger, graded grasp. Though more expensive
than body-powered prostheses, they are often more cosmetic since many do not require a harness for suspension.
However, some myoelectric TDs, such as the Greifer hook,
are bulky and robot-looking. This appearance is unacceptable to some (Fig. 31-7).
Myoelectric prostheses are expensive. They are comparatively fragile devices and frequently break down.
Greater technical skill is needed to repair and maintain
these systems. Unlike the body-powered prostheses, myoelectric systems do not tolerate many environmental
factors, such as dust and moisture. They are not as durable
or as well suited as body-powered prostheses for manual
labor. Because the weight of the prosthesis is not transferred to more proximal body parts, as in the bodypowered systems, myoelectric prostheses create more
pressure at the point of suspension, the distal part of the
limb. Additionally, they feel heavier to the user.
Precise criteria for determining the ideal control
system for each person do not exist. The patients lifestyle,
needs, funding source, and personal preference dominate
the choice. Frequently, amputees own both a bodypowered and a myoelectric prosthesis and then wear the
prosthesis most appropriate for a particular situation. For
example, the construction worker may use a body-powered
system on the job, but wear a myoelectric prosthesis at
social events (46). Recently, hybrid systems, with both
body-powered and myoelectric components, have become
more popular, since these systems can provide the advantage of both body power and myoelectric power.
In summary, a typical prosthetic restoration and
rehabilitation schedule has several stages. Initially, the
amputee is fitted with a prosthesis in the immediate or
early postamputation period. Over the next 2 to 6 weeks,
fitting and training with a preparatory body-powered prosthesis occur. Once trained, and after prosthetic needs are
determined, the amputee is fitted with a definitive bodypowered prosthesis. Typically, the amputee is ready for a
definitive body-powered prosthesis approximately 6 to 12
weeks after amputation. As a general rule, a person is fitted
with a body-powered prosthesis first. Once the individual is
successfully using the body-powered prosthesis, he or she is
evaluated for the more expensive myoelectric system.

Upper-Extremity Amputation and Prosthetic Rehabilitation

557

D
C
Figure 31-5. The amputee is fitted with a prosthesis in stages. A. First, a preparatory or provisional prosthesis is fabricated.
After a period of prosthetic training and use, the individual is fitted with a definitive body-powered prosthesis.
B. Definitive left below-elbow prosthesis with a hook but without a cosmetic cover. C. The same prosthesis
with cosmetic glove and hand. D. The definitive prosthesis used for everyday activities.

In some cases, the preparatory myoelectric fitting

phase may begin prior to the completion of the definitive
body-powered prosthesis phase. Approximately 4 to 6
months after surgery, the amputee completes the final steps
of myoelectric prosthesis training.

Harness
The harness provides suspension and a way to control the
active parts of the prosthesis. The type of socket and the

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intimacy of the fit between the socket and the residual

limb also provide suspension. The harness is composed of
a collection of strategically placed straps around the shoulder or thorax to transmit the force of proximal body
motion to the prosthetic components. The straps, which
are typically made of Dacron, must be carefully placed
and fitted so that body power is efficiently transmitted to
the active prosthetic components.
A cable system is secured proximally on the harness

D
C
Figure 31-6. Myoelectric prosthesis with a wrist rotator, prosthetic hand, and polyvinyl chloride glove. The rectangular
compartment on the medial aspect of the forearm contains the battery that powers the prosthesis.

and terminates on the TD. There are two basic types: the
single control system, which typically operates the TD for
the BE amputee; and the dual control system required by
the AE amputee. The amputee transmits muscle tension
along the stainless-steel cables of the prosthesis to perform
the desired motion. For example, in the BE amputee, the
cable terminates on the TD. The OT trains the patient to
perform coordinated movements of arm flexion and shoulder abduction to operate the TD. The body-powered AE
prosthesis uses the same principles but requires a second
cable to control the elbow unit.

Chapter 31

PROSTHESES BY LEVEL OF AMPUTATION

Partial Hand Prosthesis
A partial hand prosthesis or orthosis is useful only if it
increases function with minimal impairment of sensation
and residual hand function or if it improves cosmesis. Typically, a prosthesis is not required to improve function if
two or more digits remain. With two remaining digits, a
person is able to adduct or oppose one finger to the other.
If opposition is not possible with the remaining digits, a
rotation osteotomy may be considered in an attempt to

Upper-Extremity Amputation and Prosthetic Rehabilitation

559

D
Figure 31-7. Self-contained myoelectrically powered prosthesis with a wrist rotator and Greifer hook. On the medial aspect
of the prosthetic forearm there is a panel to access the battery. A functional arm orthosis. A hook is present on
the palm of the hand, as would be needed after a partial hand amputation. Because of the flail upper
extremity, chest expansion activates the hook. However, a partial hand amputee would use arm muscles to
activate the hook.

create opposition. If only the thumb remains, an orthosis

that provides a surface for opposition can be fabricated.
A partial hand amputation weakens grasp. Grasp
strength can be improved by fitting the person with a prosthesis with a hook, for example, to assist heavy lifting or
other work. The prosthesis is cable driven and the hook
protrudes from the palmar surface of the hand. This pro-

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vides a fine tweezer-like grasp but covers part of the

sensate residual hand. In addition, this prosthesis is difficult
to use overhead (see Fig. 31-7). Because of its appearance,
many patients do not accept the partial hand bodypowered prosthesis with a hook.
Cosmesis is the number one concern for some individuals with this level of amputation. Personal preference

Figure 31-8. For this individual with a partial hand

amputation, a cosmetic prosthesis creates a very
natural-appearing limb.

or vocational demands may require a very naturalappearing passive prosthesis (Fig. 31-8). Because the intact
human hand changes color with position, activity, or
ambient temperature, a prosthesis cannot perfectly replicate the human hand. A passive hand improves appearance while allowing the person to use the hand for limited
pushing or as a gross assist.
Cosmetic gloves to cover the TD of a prosthesis
are available. Though some very expensive gloves are
near-perfect replicas of the hand, the cost and quality
of cosmetic gloves vary. Most cosmetic gloves provide
satisfactory cosmesis and are fairly inexpensive. Cosmetic
gloves must be cared for properly to preserve their
appearance. They are also easily torn, stained, and
damaged.

Terminal Devices
The TD is the most distal component of an upperextremity prosthesis. A TD is either active or passive. A
passive TD is usually very light and has no moving parts.
However, some passive TDs are function specific; for
example, designed to hold a golf club (Figs. 31-9 and
31-10) (47).
The typical active prehension TD is a hook, hand, or
specialized device or tool with moveable parts (Fig. 31-11).

Chapter 31

The opening width of the TD must be compatible with

the ability to handle common objects. TDs can be voluntary opening (VO) or voluntary closing (VC). The hook
TD has two fingers, one stationary and one moveable.
The amputee activates the hook using either a bodypowered or myoelectric control system.
A variety of hooks are available, but the most frequently prescribed VO hook is the Hosmer-Dorrance No.
5 with neoprene grips. The tension of a VO TD opens the
fingers against resistance (i.e., rubber bands), and it is this
resistant force that holds an object if there is no cable
tension produced.
The VC TD creates more exact tension to hold an
object because the tension created in the cable results from
voluntary muscle contraction rather than the elastic action
of a spring or other elastic materials. As a result, the VC
hook has the advantage of providing graded prehension
and provides a stronger grip, as much as 20 to 25 lb
(9.0011.25 kg) of force.
Many hook designs and sizes, ranging from infant to
adult, are available to meet the demands of the individual
amputee (see Fig. 31-11). The VC TD, though more analogous to the human hand, is less popular than the VO TD.
The rehabilitation team needs to assist the individual in
selecting the most appropriate TD.

Upper-Extremity Amputation and Prosthetic Rehabilitation

561

B
A
Figure 31-9. A, B. This specialized rifle-holding terminal device allows this individual to participate in recreational target
shooting. This prosthesis is a preparatory short above-elbow prosthesis.

A
Figure 31-10. A, B. This terminal device is made specifically for holding a golf club.

In the conventional body-powered prosthesis, the

number of rubber bands located at the base of the hook
fingers determines the grip force of the TD. One rubber
band is equivalent to approximately 1 lb (0.45 kg) of pinch
between the two hook fingers. By producing tension on the
cable, the amputee is able to open or close the hook (Fig.
31-12). Though a hook is more functional, the amputee
may reject it for social and cosmetic reasons.
Prosthetic hands are bulkier and more difficult to use
than hooks. Hook TDs provide a more precise grip. The
mechanical hand, which is bodypowered, provides only
3 lb of grip force while a myoelectric hand can provide 25
lb (11.25 kg). However, both hands appear the same if a
cosmetic glove is worn over the TD.
Because of the advantages and disadvantages of the
hook and the hand, most patients prefer a prosthesis design

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that allows them to change the TD depending on the situation, for example, cutting the lawn versus going to a
wedding. If the individual intends to vary the TD, a quick
disconnect wrist is preferred over a friction wrist, which is
screwed onto the prosthesis.

Below-Elbow Prosthesis
For UE amputation the elbow is the point of reference,
that is, AE or BE amputation. This terminology is easy to
understand and readily conveys the same information to
the physician, the therapist, and prosthetist. One can
readily generalize about the upper-extremity function
remaining, the function lost, and the basic prosthetic components needed. However, terms such as transradial and
transhumeral are more accurate anatomic descriptions and
are consistent with terms used for other common levels of

A
A

B
Figure 31-12. This child demonstrates how to use humeral
flexion to open the terminal device of the
body-powered below-elbow prosthesis.
B
Figure 31-11. A variety of tools that are also terminal
devices.

amputation, such as WD and transmetacarpal amputation.

Though the terms transradial and transhumeral are preferred,
the terms above elbow (AE) and below elbow (BE) are well
established in the professional literature.
With the loss of the wrist, and possibly forearm rotation, the BE amputee needs a wrist substitute. Three basic
types of wrist units are available for conventional prostheses. The first two types provide pronation and supination
but not wrist flexion and extension. The amputee must
position the wrist unit in the desired position of pronation
or supination. The variable friction wrist unit adjusts for
variable rotation friction, that is, from loose to tight. Most
individuals prefer the quick-change wrist units because the
amputee can change the TD quickly.
The third type, the wrist flexion unit, provides not
only variable friction for wrist rotation but also wrist
flexion. This is an important option for the bilateral

Chapter 31

amputee, or the person with a nonfunctional contralateral

limb, who is dependent on the prosthesis to do midline
activities, such as dressing. In the bilateral amputee, this
unit is placed on the dominant upper-extremity prosthesis.
Unilateral amputees rarely require this type.
These three units fulfill the basic purpose of a wrist
unit; that is, they act as a site for attaching and positioning
the TD. The wrist units available for the forearm after WD
are considerably thinner than the standard wrist unit but
typically do not lend to a quick interchange of TDs.
There are three basic types of elbow hinges: the flexible hinges, the rigid hinges, and step-up hinges. In the
presence of a long residual forearm, flexible elbow hinges
allow natural forearm rotation. Rigid hinges impede this
motion. However, because functional pronation and
supination motions are lost as the residual forearm
becomes shorter, flexible hinges become unnecessary. Rigid
hinges are a better option for the shorter residual forearm
because more forearm stability is needed.
The individual with a very short limb after transradial amputation can benefit from step-up hinges since

Upper-Extremity Amputation and Prosthetic Rehabilitation

563

B
A
Figure 31-13. A step-up elbow amplifies the amount of natural elbow flexion in the individual with a very short limb after
below-elbow amputation.

anatomic elbow flexion is usually limited to less than 90

degrees. These hinges amplify the range of motion (ROM)
at the elbow in a ratio of 1 : 2. For instance, 50 degrees of
elbow flexion results in approximately 100 degrees of prosthetic flexion. The step-up hinge design requires that the
socket be a separate unit from the prosthetic forearm (split
socket design) (Fig. 31-13). Unfortunately, though flexion is
increased, the lever arm force is reduced approximately
50%. The force applied to the volar surface of the residual
forearm is high and many patients do not tolerate the pressure. This system is preferred for the amputee with a very
short residual forearm with limited ROM for whom
increased ROM is more important than strength. These
hinges can be very useful, particularly for the bilateral
upper-extremity amputee.
The distal inner socket in the long BE, or transradial
prosthesis, characteristically is flat to capture the natural
pronation and supination of the forearm and to transmit
this motion to the TD. The triceps cuff transfers the forces
between the socket and the shoulder harness. The
Muenster-type socket often is used in the case of the short
BE amputation. It reduces the amount of suspension needed;
however, a cable system is still required to operate the TD.
Two basic types of harnesses are available for the
patient who underwent transradial amputation: the figureof-eight harness and the shoulder harness with a chest
strap. Because the figure-of-eight harness allows for the
widest range of activities with the least restriction, it is the
most common harness used by unilateral and bilateral
upper-extremity amputees. It is the harness of choice for
women because there is no chest strap to interfere with

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Therapeutic Interventions

clothing. A figure-of-nine harness affords more freedom of

motion and is an excellent choice for a BE prosthesis, but
usually requires supracondylar suspension as well.

Elbow Disarticulation Prosthesis

The person who has undergone ED needs mechanical
replacement of elbow flexion and extension. There is little
room for a standard prosthetic elbow, however. To avoid
making the prosthesis too long when compared to the
intact upper extremity, an external locking elbow joint is
required rather than the standard internal locking joint.
These units are less cosmetic and easily damage clothing.
However, ED can be a valuable option for the bilateral
amputee who must use a residual limb for self-care. ED is
preferred in children to avoid the complication of bony
overgrowth associated with diaphyseal amputations.
Because an ED prosthesis requires the individual to
control both elbow and TD functions, a dual type of
shoulder harness is needed. Humeral rotation, preserved
by disarticulation, is captured by configuring the internal
distal socket with an oval shape and achieving an intimate
socket-limb interface in the region of the humeral
condyles. Only about 50% of available humeral rotation is
transmitted to the prosthesis, however.
The physical characteristics of the residual limb
influence the socket design prescribed. For this level of
amputation, there are basically three options available:
socket with a fenestration or window, a screw-in type of
socket, or a socket with supracondylar wedges. Sockets
with pneumatic bladders are available. Though used infrequently, pneumatic bladders are an option for the person

Figure 31-14. An example of an above-elbow prosthesis

being used as a functional assist. Note the
internal locking elbow unit with an externally
attached forearm lift assist (spring loaded).

with a bulbous distal limb or whose limb volume varies

significantly.
Sockets with flexible inner liners, like those used for
lower-extremity prostheses, are popular among upperextremity amputees. They are cooler than the standard
hard socket. Made of moldable plastics, these liners are
thin and accommodate changes in limb shape and volume
that occur with muscle contraction. Many amputees find
these more comfortable than other sockets.

Above-Elbow Prosthesis
The shorter the remaining humerus is, the more the
patient loses rotation, power, and leverage. An amputation
at or below the distal third of the humerus affords the
amputee many of the advantages of ED, but supracondylar suspension and rotation control are lost. Though scapular motion provides some control, humeral motion
provides primary control for the transhumeral prosthesis. A
figure-of-eight harness with dual-control design is the most
popular system.
Transhumeral amputation that is performed at least
5 cm proximal to the elbow leaves a limb that can
accommodate an internal or inside locking elbow unit (Fig.
31-14). The turntable multiple locking elbow unit, which is
the most common unit used by the AE amputee, has 11
locking positions. It provides 5 to 135 degrees of flexion,
whereas the elbow unit used in a disarticulation prosthesis
has only seven positions, or fewer if it is a heavy-duty
design. With a body-powered prosthesis, if the elbow is
unlocked, pulling the cable flexes the elbow. If however
the elbow is locked, a pull on the main cable operates the
TD (48).
A residual limb of less than 10 cm after transhumeral
amputation can be fitted with an AE prosthesis but often
requires a forearm spring lift assist incorporated into the
elbow unit. The most proximal transhumeral amputation

Chapter 31

Figure 31-15. Forequarter body-powered prosthesis. The

prosthetic components include a chest strap,
detachable shoulder cap, single-control
terminal device cable, passive locking elbow,
quick-change wrist, and hook terminal
device.

that results in a functional limb is performed at approximately 5 cm distal to the axillary fold. A shorter residuum
is unable to control the prosthetic socket effectively (49).
Hybrids of myoelectric and body-powered systems
are very valuable for the AE amputee. A body-powered
elbow with a myoelectric hand is a common choice. The
myoelectric hand, with its stronger grip and graded
control, is valuable for the person whose work or avocation
involves a lot of holding and stabilizing objects. The myoelectric elbow with a body-powered TD affords more
sensory feedback for the patient who needs feedback
regarding TD function.

Shoulder Disarticulation and Forequarter Prostheses

At this level of amputation the majority of upperextremity
function is lost. The patient has little residuum to operate a
prosthesis. More mechanical replacement is required to
compensate for the lost hand, wrist, elbow, and shoulder
function (Fig. 31-15). In general, the individual needs a
TD, wrist rotator, elbow flexion-extension unit, and a
locking turntable. Passive shoulder positioning is required.
Not surprisingly, the prosthetic rejection rate is highest
among these patients. For some persons, this level of prosthetic replacement represents overgadgetization, that is,
more technology than they find functional or tolerable.
These individuals often opt for a simple passive prosthesis
for aesthetic reasons. Others choose no prosthesis at all.

Upper-Extremity Amputation and Prosthetic Rehabilitation

565

Depending on the shoulder profile remaining, stabilizing a prosthesis can be difficult. Sockets are fabricated
using plastic laminates. Control of perspiration is more
problematic than with more distal amputations. The prosthetist is challenged to achieve an intimate socket-limb
interface to suspend the prosthesis while providing sufficient ventilation. Moisture-absorbing material placed or
worn under the socket (e.g., cotton T-shirt) helps to control
perspiration. Antiperspirants that control excess perspiration and need only to be used once or twice weekly are
available commercially. The weight of the prosthetic arm
creates high pressure over bony prominences. During
socket fabrication, sufficient relief must be provided in
these areas to avoid pain and skin breakdown.
Some individuals benefit from a prosthetic shoulder
joint while others prefer a bulkhead design. With the
bulkhead design, the prosthetic humerus is attached
directly to the socket and no shoulder motion is provided.
Omitting the shoulder unit reduces the weight of the
prosthesis, making it very attractive to some amputees. At
this level, a lightweight endoskeletal prosthesis is also an
option.

Currently, shoulder units require passive positioning.

Basic types include the single-axis joint that allows
only shoulder abduction, the double-axis unit that provides
shoulder flexion and abduction, and the four-way friction
shoulder design that allows full passive motion. The shoulder flexion and abduction unit is the most common and
most functional.

Cosmetic Prosthesis
For some patients, cosmesis far outweighs the need or
desire for a functional prosthesis. Some individuals are not
able to operate a prosthesis. Often individuals whose upper
extremity was amputated at a very proximal level prefer a
cosmetic prosthesis and do not want a prosthesis with
active components. Individuals with an FQ amputation or
SD may do best with a simple shoulder cap to restore the
profile of a normal shoulder (Fig. 31-16). The physician
must know the patient and keep in mind that prescribing a
prosthesis is typically a compromise between cosmesis and
restored function. Hybrid systems of passive and active elements, with body-powered and externally powered components, are often the best choice.

A
B

C
Figure 31-16. Forequarter amputation. Individuals who have had an amputation at this level often prefer a simple shoulder
cap without other prosthetic components. This passive prosthesis restores the shoulder profile, improving the
fit of clothing, but does not provide additional upper-extremity function.

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PEDIATRIC PROSTHETICS
Upper-extremity limb loss in children is most often congenital. The etiology is highly variant, ranging from maternal infection, chemical or drug exposure, and amniotic
band syndromes, to single gene mutations. Though some
congenital limb deficiencies are associated with known syndromes, for example, craniofacial and thrombocytopenia
absent radius (TAR) syndromes, or thalidomide exposure,
the majority is of unknown etiology. The most common
congenital limb loss is transverse deficiency of the proximal third of the left forearm (Fig. 31-17).
Acquired limb loss accounts for 40% of pediatric
limb loss, typically involving a single limb; 60% involves
the lower limb. Trauma is the most common cause; tumor
and disease are next in frequency. With trauma, the limb
loss is primarily due to power tool accidents, burns, and
motor vehicle accidents. In the toddler and preschooler,
power tools, such as lawn mowers, and household accidents are the primary causes. Regarding surgical amputations for disease, more than half are secondary to
malignant tumors in preadolescents and adolescents.
Over the years, efforts have been made to classify
and describe congenital limb deficiencies. Much of the terminology, being imprecise and ambiguous, generated confusion. The International Organization for Standardization
(ISO), involving the work of the International Society for
Prosthetics and Orthotics (ISPO), has developed a widely
accepted classification system and standard terminology for
congenital limb deficiency. There are two major classifications: transverse limb deficiencies and longitudinal limb
deficiencies. The system is restricted to skeletal absence or
reduction and does not consider the etiology or embryology. Since the classification is restricted to the absence or
reduction of normal skeletal elements, radiography, or
other methods to identify skeletal elements, is used. Lack of

Figure 31-17. Transverse deficiency of the proximal part of

the left forearm is the most common
congenital limb deficiency.

Chapter 31

a skeletal element beyond a certain level is classified as a

transverse deficiency. The limb has developed normally to
a certain level, after which no further skeleton exists distally. In transverse limb deficiency, often limb bud remnants (often referred to as nubbins) are present. The
transverse level is named by the terminal bone and the
level at which no further skeletal elements exist. All other
limb deficiencies are described as longitudinal deficiencies,
that is, skeletal absence or reduction in the skeletal long
axis of the arm or leg.
The child with a congenital limb deficiency is fitted
with a prosthesis in accord with the childs developmental
stage. A child with an upper-extremity deficiency can be
fitted with a passive hand prosthesis at 2 to 3 months old
to facilitate the development of hand skills.
Children with partial hand amputations or congenitally absent digits are typically not fit with a prosthesis
because of the sensory loss created by the device covering
areas of sensation. Children are very adaptable and function very well without a prosthesis. Often, a prosthesis adds
little function at this level. Like adults, opposition posts and
pads can be used. Acceptance of these devices is variable
and often are task specific. A childs acceptance is affected
by the function provided by the device and by the attitude
of parents or caregivers toward the prosthesis or orthosis.
Children with limb deficiency or loss at a more proximal level benefit from a prosthesis, and need to be fit at a
young age before they develop compensatory techniques
that preclude the use of a prosthesis. If a child has not
been fitted and trained by the age of 2 years, the rejection
rate is significantly higher than it is for those fitted before
age 2. For the child with a congenital deficiency, a prosthesis must add function or the child will reject it. In the child
with a traumatic or surgical amputation, the prosthesis
provides both limb replacement and functional restoration.
Children are very active and require prostheses that are
durable and functional. Like adults, children who have had
an amputation benefit from early prosthetic fitting.
Children require frequent refitting. A child may
require socket modification or replacement to accommodate limb growth as often as every 3 to 6 months. Many of
the previous prosthetic components can be reused in the
replacement prosthesis. The use of multilayered sockets
reduces the need for socket replacement as they can be
easily modified to accommodate growth. Removable
growth liners or flexible liners, which are composites of silicone and polyethylene, can reduce the frequency of socket
replacement.
Cosmesis is important in pediatrics. Often the
appearance of the prosthesis is more important to the
parents than it is to the preschool child. Parents want the
child to appear normal, as much for the childs sake as
theirs. Once the child enters school, he or she becomes
more concerned about appearance. Children, like adults,
want to be accepted by peers and not perceived as different or odd.

Upper-Extremity Amputation and Prosthetic Rehabilitation

567

Current technology produces smaller, simpler, and

more durable myoelectric units. As a result, pediatric
patients can be fitted at a very early age. Myoelectric
systems are available for children who have undergone
WD or a transhumeral amputation (50). The transradial
myoelectric prosthesis is the most commonly prescribed for
any age group.
The appropriate age to fit a child with a myoelectric
prosthesis is debated. Some clinicians argue that a myoelectric prostheses can allow normal hand development
earlier than body-powered systems do. Some rehabilitation
centers fit children with myoelectric prostheses as early as 6
to 9 months old. Others wait until the child is of the
preschool age and is proficient with a body-powered prosthesis. This approach maximizes the development of the
residual limb and is less costly. These children become proficient with both body-powered and myoelectric systems.
Proponents of early fitting argue that children are
developing pinch as early as age 3 to 4 months. These clinicians argue that these infants do not have the shoulderarm coordination required for body-powered prostheses
until the ages of 12 to 18 months. They propose that
fitting the infant with a simple myoelectric prosthesis eliminates the problem of shoulder-arm incoordination and
allows the child to learn pinch at an earlier age. Though
prescribing myoelectric single-function TD for a child as
young as 6 to 9 months is controversial, more clinicians are
prescribing myoelectric prostheses at earlier ages (51,52). It
is never appropriate for chronologic age to be the sole
determinant of whether a child is or is not prescribed a
myoelectric prosthesis. The childs needs, skills, and overall
psychosocial situation determine which control system is
most appropriate (50).
The young child who has undergone AE amputation
is usually fitted with a static or friction elbow prosthesis.
An active functional elbow, operated by cable or external
power, is provided to older children. Often children with a
long residual limb after transhumeral amputation function
best with a body-powered system, rather than an externally
powered one, since a body-powered system weighs less.
Like adults, children who have a very short residual
limb after transhumeral, FQ amputation, or SD often
reject prostheses. They must experience significant gains,
particularly in terms of function, to tolerate the weight, the
hassle, and other limitations of prostheses prescribed for
this level.
Like adults, many older children do best owning
both a body-powered prosthesis and a myoelectric one.
They need a choice in TDs as well. Children with both a
hook and hand TD, as well as a body-powered and a
myoelectric prosthesis, can wear the prosthesis and TD
appropriate for the situation. Overall, the best prosthetic
choices are made when the rehabilitation team, the child,
and the family work together to determine prosthetic
options.
Children with more than one congenital limb defi-

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ciency are very challenging. The child with a unilateral

upper-limb deficiency uses the prosthesis primarily as an
assist device and uses the contralateral upper extremity as
the dominant limb. The child with bilateral upperextremity deficiency does not have this option. Ideally, the
bilateral amputee needs to be independent with and
without the prosthesis. Many children need to learn to use
their feet for ADLs and other activities (e.g., writing). An
experienced rehabilitation team is essential for the best
outcome in these complex cases.

PRESCRIBING A PROSTHESIS
No two individuals are alike. No one prosthesis fits all
patients. Prescribing an upper-extremity prosthesis requires
the integration of a number of medical, rehabilitation,
social, and economic factors. The rehabilitation team not
only must assess the patients needs, preferences, capabilities, and overall medical condition, but also must consider
the anatomy of the residual limb, the functional status of
the residual limb and proximal joints, the presence of any
other impairments, and the individuals socioeconomic
situation. If this information is synthesized and incorporated into the prosthetic restoration and rehabilitation
program, the patient will receive the most appropriate
prosthesis.
The essential components of a typical functional
upper-extremity prosthesis are the socket, suspension
system, control system, and TD. The suspension system
includes cuffs and a harness. The control system is either
body powered, externally powered, or a hybrid of both.
The level of amputation determines whether a TD, wrist
unit, elbow hinge or elbow unit, and shoulder component
are needed. If the prosthesis is primarily cosmetic, few
mechanic components, if any are needed (Fig. 31-18).
It is important to prescribe the most functional, comfortable, and cosmetic prosthesis for the individual. As an
example, the most commonly prescribed generic BE prosthesis typically includes a VO split-hook TD, quickdisconnect wrist unit, flexible elbow hinge, double-wall
laminated socket, single-control cable system, triceps cuff,
and a figure-of-eight harness. For the generic AE prosthesis, the same components are used but an elbow unit and
a dual-control cable system are added.

PSYCHOSOCIAL IMPACT OF UPPER-EXTREMITY

AMPUTATION
Each person who experiences an amputation grieves the
loss of limb and function. Clinicians recognize that the
grief process varies among individuals. However, many
clinicians recognize that this process is very similar to the
grief accompanying other major losses, such as divorce,
terminal illness, and death of a loved one. The phases of
grief, first described by Kubler-Ross in patients with

Figure 31-18. An upper-extremity prosthetic prescription form that accurately communicates the type of upper-extremity
prosthesis prescribed. It also ensures that clinicians prescribe all the essential components and options
specifically needed for each amputee.

terminal illness, are shock, denial, anger, depression, and

acceptance (5355).
Every individual feels a personal loss but the grief
felt by the amputee is not directly proportional to the physical extent of limb loss. For example, the salesman who has
lost his right hand may perceive the loss as deeply as the
electrical lineman who has lost the entire upper extremity.
The lineman may adjust more easily while the salesman
experiences more grief because of the appearance of his
hand for social greetings, whether at work or socializing. It
is crucial for the rehabilitation team to be aware of the
individuals response to amputation. Peer counselors can
help the patient realize that there is life after amputation. Referral to mental health professionals, ideally
someone experienced working with individuals with limb
loss, can assist individuals whose grieving exceeds the parameters of normal grief.
Every amputee eventually grieves, but not everyone
does so at the same rate. Some reach acceptance quickly,
while others are still grieving 10 years later. Clinicians
report that the grief process lasts approximately 2 to 3
years. The individuals past experiences, cultural background, premorbid personality, coping skills, current interpersonal relationships, and support systems impact the
individuals ability to achieve acceptance of the limb loss.
Grieving is a dynamic process and may recur. Later events,
such as a wedding, may remind the individual of the
impact of the limb loss on personal appearance and life
choices. Typically, the anger, irritability, and depression
associated with the loss eventually resolve. Life resumes.
The amputee works, socializes, and plays. The individual is
different because of the amputation. The amputee does
not like it, but it is okay. Life is different but not over. It is
something the individual can live with. Unfortunately,
some never reach this level of acceptance.
The amputee is not the only one who grieves. Family
and loved ones also grieve, though less intensely. Children,
who experience traumatic loss, tend to move through
the grief process more quickly than adults. Parents of
children with congenital limb deletions feel responsible
and grieve deeply, while the infant is unaware of the deficiency. However, at a later age, when other children or
adults react to the childs limb loss, the child learns that
she or he is different. The child may grieve and wonder
Why do I have to be different? The experiences of the
various psychosocial and physical stages of maturation
remind the amputee of the impact of limb loss on his or
her life.
Limb loss is difficult at any age. Grief is painful.
However, normal grief allows the person to adjust to the
loss and to progress through rehabilitation to a full and
productive life. The rehabilitation team must acknowledge
the individuals loss and support the individual through the
process. Direct discussions about limb loss, the personal
and social impact, and prosthetic restoration and rehabilitation assist the amputee in accepting the loss. However,

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some patients need professional psychological assistance.

Others thrive on their own.

PRE-PROSTHESIS MANAGEMENT
Ideally, one would like to begin prosthetic restoration
and rehabilitation before amputation. However, most
upper-extremity amputations are performed emergently.
Generally, there is little time to prepare the individual
for amputation or prosthetic restoration and
rehabilitation.
If the surgery is elective, the patient, the physicians,
and the rehabilitation team are able to collaborate and
develop a treatment plan. There is also time to educate the
patient about the level of amputation, preoperative and
postoperative course, functional implications of the amputation, and available prosthetic and rehabilitation options.
Additionally, the patient is counseled about phantom pain
and sensation as well as psychosocial concerns.
Unfortunately, the patient and the members of the
rehabilitation team typically do not meet until after
surgery. However, patient assessment and education should
begin as soon as possible. An initial assessment is performed. Information is collected about the individuals preamputation functional level, including vocational and
recreational activities, upper-extremity dominance, and
psychosocial situation. The initial assessment, or inventory,
begins the process of determining the individuals prosthetic and rehabilitation needs. An individualized prosthetic rehabilitation program is initiated, integrating
multiple factors including the status of the residual limb,
the patients overall functional status and general health,
the persons financial resources, and the amputees goals
and expectations.
As a rule, ADL training does not begin until a
person receives a prosthesis. If the individual becomes
adept doing activities with one hand he or she is less likely
to accept and use a prosthesis. Learning to be one-handed
initially seems an acceptable option. However, after 20 or
30 years of performing activities with one hand, individuals who have not used an upper-extremity prosthesis frequently develop cumulative trauma syndromes of the back,
neck, and the intact upper-extremity. Bilateral upperextremity amputees are the exception to the rule. All
efforts should be made to enable these individuals to begin
feeding and performing ADLs as soon as possible, even
before a prosthesis is available.
Other rehabilitation issues addressed early after
amputation include wound management, edema and pain
control, scar management, range of motion of the limb,
and upper-extremity strength.

Wound Management
The surgical site requires close monitoring until healing is
well established. The surgeon prescribes necessary postoper-

ative limb care, including the type of dressing and incision

care. Surgeons opinions vary about when a surgical site can
tolerate the fitting of a posthesis. Typically, the preparatory
prostheses can be fit when small open wounds are present
and healing is occurring uneventfully. In most cases, wounds
tolerate prosthetic fitting within 2 to 3 weeks.

Edema Management and Early Limb Shaping

Edema control is important to enhance healing, reduce
pain, and begin shaping the residual limb for prosthetic
fitting. Initial compression of the residual limb is provided
by a rigid dressing or elastic wrap or bandages. As mentioned earlier, a rigid dressing (cast) applied intraoperatively over the surgical dressing effectively limits
postsurgical edema. However, compression is usually
applied after the bulky surgical dressing is removed, which
often occurs on postoperative day 1 if primary skin closure
was performed. If skin grafting was performed, the application of compression is usually delayed 1 to 2 weeks.
The OT teaches the patient and family members
how to apply appropriate compression. If the wound is
draining, minimal dressing is applied over the incision
before compression is applied. If the wound has no
drainage, no dressing is required under the compression
wrap. A figure-of-eight or herringbone elastic wrap technique is used to apply compression for transmetacarpal
levels or shorter.
When the residual limb has healed, a custom-fitted
compressive sock works well. A custom compressive
garment very effectively stabilizes limb volume and is easy
to don and doff. Clinical experience indicates that compression reduces phantom sensation and pain and controls
scar formation. Usually, no more than two compression
socks should be worn simultaneously. Some individuals find
that they always need to wear a compressive garment to
control limb volume and shape.

Range of Motion
After an uncomplicated amputation, the patient is
instructed in active ROM exercises for all residual joints on
the first postoperative day. If other injuries are involved,
such as fractures, skin grafts, and tendon repairs, appropriate restrictions are observed. Full active ROM is expected
for all joint motions with the exception of forearm or
humeral rotation, which depends on the residual bone
length. If full ROM has not been achieved after 1 week,
passive ROM exercises are added.

Pain Management
Patients experience pain after an amputation. Postoperative
incision pain can be controlled with appropriate postsurgical analgesia and resolves over a week or two. However,
other types of pain may persist after the surgical recovery
period. When managing pain, it is important to determine

Chapter 31

the etiology, for example, secondary to the pathomechanics

of an arthritic joint or due to extrinsic factors such as an
ill-fitting prosthesis. Phantom pain is a common but poorly
understood problem.

Phantom Sensations and Phantom Pain

Phantom sensation and phantom pain are distinct syndromes. Phantom sensation, the perception a missing limb
is still present, is a common postoperative experience. Typically, patients do not require treatment for these sensations. These phantom feelings are not painful but they
can be annoying. The sensations change and fluctuate over
time. The phenomena of telescoping and fading may also
occur. With the phenomenon of telescoping, or regressive
deformation, the phantom limb is perceived as shortening.
Fading is the perception that the proximal part of the
phantom limb is shortening and the most distal part
of the phantom limb is regressing proximally; for example,
the phantom hand feels as if it is at the stump site. These
sensations (e.g., itching or tingling) occur more frequently
after upper-extremity than lower-extremity amputation.
On the other hand, phantom pain is a painful sensation seemingly occurring in the missing limb or segment.
The distribution of the perceived pain may or may not
occur in a dermatomal pattern. Typically most prominent
immediately postoperatively, the pain can range from mild
to severe. Phantom pain is rare in children, especially before
the age of 7 years. In general, phantom pain improves and
resolves over time. However, a small percentage of patients
experience persistent phantom pain that is debilitating.
Phantom sensation and phantom pain are puzzling
experiences for the uneducated patient. Patients should be
taught that these are not unusual experiences and that they
are not losing their mind Teaching the patient about
phantom sensation and pain reduces anxiety, which in itself
heightens the perception of pain. Effective treatment is
available for the pain.
Patients describe phantom pain in a number of
ways: burning sensations, shooting pain, muscle cramping,
as well as the sense that the limb is in a painful position.
Typically, phantom pain is worse at night, after the extremity has been in a dependent position or after the prosthesis
has been off for a period of time. Phantom pain is experienced mainly in the distal aspect of the phantom extremity. Sometimes, patients can identify specific points on their
limb that trigger phantom pain. Examination of the residual limb can determine if these points correlate with neuromas, cysts, or sites of excessive weight bearing or
pressure. In addition to an ill-fitting prosthesis or mechanical stimulation precipitating phantom pain, other precipitating factors occasionally reported include fatigue,
micturition, defecation, and even yawning.

Strength and Endurance Training

Strength and endurance are required to operate a prosthesis successfully. Exercises are prescribed to improve the

Upper-Extremity Amputation and Prosthetic Rehabilitation

571

strength and endurance of muscles, particularly those

muscles that will operate the prosthesis. This is particularly
important in patients with known weakness around the
glenohumeral joint and scapula.

PROSTHETIC CHECKOUT
When the patient receives any prosthesis, preparatory or
definitive, the OT checks the prosthesis to make sure it is
just what the doctor ordered (56). In addition to verifying that the prosthesis meets the specifications of the prosthetic prescription, the OT evaluates cosmesis, comfort, fit,
control efficiency, stability of suspension, and the mechanical components of the prosthesis. Ideally, the prosthetist is
present and makes the appropriate modifications before
the amputee takes the prosthesis home (57).
The prosthesis should appear to be the same length,
circumference, and shape as the sound extremity. The
prosthesis should not have the same dimensions as the contralateral side or it would appear too large and bulky.
Proper length is achieved when the end of the hook or the
tip of the prosthetic thumb is level with the tip of the contralateral thumb with the arms extended at ones side
(5860). Length is important not only for appearance but
also for the most effective use of the TD. For example, if
the prosthesis is too long it will interfere with hand-tomouth activities. The cosmetic glove covering the prosthetic hand needs to be similar in color to the sound hand.
No glove will match the color of the intact hand exactly,
but reasonably priced cosmetic gloves that provide a good
match are available commercially.
Comfort is a major issue. The amputee will not wear
a prosthesis that causes pain. The socket should provide
even pressure on the residual limb. Pressure should be
eliminated or reduced at bony prominences or neuroma
sites. The socket should not leave red skin marks that last
more than 15 to 20 minutes after removal of the prosthesis. Skin irritation, breakdown, or pain suggests an unsatisfactory fit. Modification of the socket fit or suspension
system usually corrects these problems.
The prosthesis should permit maximal active ROM
of the residual limb. Often this is not feasible with a very
short residual forearm or Muenster-style sockets
(41,6163). Though harnessing systems may preclude full
shoulder flexion or abduction, active shoulder flexion
should be no less than 90 degrees (41).
The mechanical efficiency of the control system of a
body-powered prosthesis is evaluated. Stable suspension of
the prosthesis is also crucial. With a 25-kg axial load (i.e.,
50 lb or one-third of the body weight of a child), the
amount of socket displacement on the residual limb should
not exceed more than approximately 2.5 cm (41,6163). If
the socket migrates more than 2.5 cm, the harness needs
modification.
The checkout procedure is slightly different for the

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externally powered prosthesis. An experienced therapist

listens to the electronics, monitors the speed of movement,
and determines if the correct control muscle is utilized
(e.g., wrist extensors for opening TD, not closing TD). In
addition, the therapist checks the mechanical components
of the prosthesis to determine that they are functioning
properly.

PROSTHETIC TRAINING
Prosthetic training that focuses on the patient increases the
likelihood that he or she will effectively use the prosthesis.
Typically, patients learn to use the prosthesis by trial and
error once they have been instructed in the specific control
motions. Not all amputees approach activities using the
same technique. Amputees who are experienced with tools
tend to find training easier than those who are unfamiliar
with tools. The OT acts as a facilitator, encouraging independent problem solving and providing guidance and assistance as needed. Only one therapist should do the training
or the amputee will become confused by the different
approaches. An experienced therapist who is a strong
advocate of prosthetic use significantly increases the likelihood of successful prosthetic training (41). The amputee
who is not fitted with a prosthesis during the 30-day
golden period needs to relearn how to perform activities
once the prosthesis is fitted. Having to abandon onehanded techniques and relearn prosthetic techniques
reduces the likelihood that the individual will become a
successful user of the prosthesis.
The individual must have realistic expectations
regarding what the prosthesis can and cannot do. The
amputee must consider the prosthesis as an assist. In a
unilateral amputee, the prosthesis assumes the role of a
nondominant upper extremity for activities. If the amputation involved the individuals dominant hand or arm,
the contralateral limb assumes dominance. Typically, bilateral amputees use the longer residual limb as the dominant
one.
Prosthetic training is divided into three distinct
phases: orientation, controls training, and use training.
During prosthetic orientation, the patient learns about
prosthetic components. General instructions in the wear
and care of the prosthesis are reviewed. During prosthetic
controls training, the individual learns to operate all prosthetic components. The amputee must learn to operate the
components smoothly and efficiently, avoiding strain or
awkward movements. During prosthetic use training, the
person learns to perform ADLs with the prosthesis. Bilateral tasks, such as cutting with scissors, cutting meat, and
tying shoes, are emphasized.

Prosthetic Orientation
The patient first learns how to wear the prosthesis. Typically, the amputee learns to don and doff the prosthesis
using either a pullover technique or a coat technique. The

amputee initially wears the new prosthesis for periods of

30 to 60 minutes, and then gradually increases the wearing
time. Within 1 or 2 weeks, the amputee should be comfortably wearing the prosthesis for an entire day. New
amputees continue to wear shrinker socks or elasticized
wraps when not wearing the prosthesis. This is required
until the volume of the residual limb stabilizes, or indefinitely in patients with fluctuating limb volumes.
The wearer of a conventional, or body-powered,
prosthesis is taught how many socks to wear and the indications for changing the number of socks. The amputee
must learn how many rubber bands to put on the VO
hook. Typically, the individual begins with about 1lb
(0.5 kg) of pressure, as measured by the pinchometer. The
number of rubber bands is gradually increased until sufficient pressure is provided to meet the amputees functional
needs, that is, 3 to 15 lb (1.356.75 kg) of pressure. Generally, BE amputees need approximately 8 lb (3.6 kg) of pinch
force, while AE amputees develop about 5 lb (2.25 kg) of
pinch force with the VO hook.
The amputee is able to communicate effectively with
the team once he or she learns to identify basic prosthetic
components (64). Basic prosthetic concepts should be introduced as well. The prosthetic rehabilitation team, on the
other hand, must learn to discuss aspects of prosthetic
restoration and rehabilitation in lay terms.
Since many amputees require more that one TD,
they must learn to switch from one TD to another and the
indications for the various TDs. Users of conventional
prostheses often learn to change cables and adjust the
harness to improve control.
It is important for amputees to learn to care for limb
socks, sockets, harnesses, cables, TDs, rubber bands, cosmetic gloves, and batteries. They are taught auditory and
visual clues that indicate malfunction or deterioration.
Amputees are to contact the prosthetist as soon as a malfunction is detected, to prevent further damage.

Conventional Prosthesis Controls Training

The patient learns the proper body mechanics and
motions to operate all prosthetic components. Eventually,
the amputee will perform the appropriate motions automatically. For most amputees, basic controls training is
accomplished in 30 minutes.

Basic Controls Training

There are two parts to basic controls training: opening and
closing the TD and learning to preposition it.
Opening and Closing the Terminal Device
The patient learns to open and close the TD and to activate the TD with the elbow and shoulder in different positions, including full flexion and full extension. For instance,
the amputee learns to activate the TD using the control
motions of humeral flexion, biscapular abduction, or
shoulder depression.

Chapter 31

Prepositioning the Terminal Device

The person learns to strategically place the TD in a
position to grasp the object most easily. Using the sound
hand, the unilateral amputee passively pronates or
supinates the TD into the desired position. Next, the
stationary finger of the hook or hand touches the object
and the movable hook or fingers grasp the object. To
position the TD, the bilateral amputee uses the other
TDs or pushes the TD against the body or a stable object,
such as the edge of a table. The friction wrist should be
tight enough to maintain the hook or hand in position
when the cable is activated. The bilateral amputee with a
wrist flexion unit learns to position the unit and the TD
close to the body, for activities such as toileting, eating, and
shaving.

Above-Elbow Controls Training

In addition to the above-mentioned techniques, the AE
amputee learns additional control techniques. Typically, an
additional 30 minutes of training is necessary to learn
these skills.
Elbow Flexion and Extension
The patient learns how to activate elbow flexion. With the
elbow unlocked, the patient learns that humeral
flexion causes the prosthetic elbow to flex. This is the
same motion that operates the TD if the elbow unit is
locked.
Elbow Locking Mechanism
The AE amputee learns to activate a second control cable
for locking and unlocking the internally or externally
hinged elbow. The amputee learns to use elbow nudging to
lock and unlock the elbow hinges. Sometimes, this is a difficult motion to learn. This motion, often described as
down, back, and out, combines humeral extension and
abduction with scapular downward rotation and depression
to control the elbow hinges (48). There are other control
motions for activating the elbow cable. Some prosthetists
design the cable so it goes through a pulley on the shoulder saddle and then attaches to a belt loop. Shoulder elevation activates this system. The patient learns to listen for
the clicking sounds made by the elbow locking cable as a
cue to verify that the elbow lock is on or off. Elbow locking
in various degrees of elbow flexion and extension is also
learned.
Humeral Turntable
AE amputees who lack 5 cm or more of humeral length
benefit from a humeral turntable. The humeral turntable,
located just proximal to the internal locking prosthetic
elbow, requires passive prepositioning into the appropriate
amount of internal or external rotation. The turntable
must be tightened enough so that the selected position is
maintained when the TD is activated.

Upper-Extremity Amputation and Prosthetic Rehabilitation

573

Shoulder Disarticulation and Forequarter

Controls Training
Control Motion
Typically, these individuals use chest expansion to activate
the cable for TD use. This strap attaches both anteriorly
and posteriorly to the prosthetic socket. Full cable excursion is often an unrealistic goal, and as a result, full voluntary TD opening is not achieved. Often the amputee is
unable to provide sufficient strength to utilize a bodypowered prosthesis and finds it is more work than it is
worth. For these individuals, externally powered components may be a good option.
Four-Way Friction Shoulder Hinge
If the patient chooses to have a shoulder unit, this type is a
frequent choice. The patient is taught how to passively
(manually) preposition the prosthetic arm in humeral
flexion or extension, adduction or abduction, or any
combination.
Nudge Control
This button or lever mechanism is on the thoracic shell
and enables the individual to engage or disengage the
elbow lock. Typically, the amputee uses the chin to operate
the nudge control. The individual passively positions the
elbow into the position appropriate for the task and locks
it. This option is selected when other motions are not
available to control the prosthesis.

Externally Powered Controls Training

Myoelectric Site Selection and Training
Controls training for the myoelectric prosthesis is begun
before the patient is fitted with the prosthesis. Selection
and training of appropriate control sites is most important.
An experienced therapist or prosthetist is essential to successful training (57).
The amputee must be able to generate sufficient
muscle contraction to activate the myoelectric sensor contained in the prosthesis. Possible myoelectric control sites
are tested using an electronic biofeedback system or a myoelectric tester that provides quantification of the electrical
potential generated by the selected muscle site (Fig. 31-19).
The most distal site with the strongest signal is chosen. As
a rule, muscles that approximate normal motion are
selected. For instance, wrist flexors and extensors are
selected to close and open the TD of the BE prosthesis.
Control of muscle site signals is the basis of successful myoelectric prosthesis use. Dual-site control is preferred
over the more difficult single-site control. With dual-site
control, two muscles must be able to generate independently a sufficient electrical potential to operate the prosthesis without interfering with each other. Typically, the
patient is taught to isolate antagonist muscles. For example,
BE amputees learn to isolate the wrist flexors and exten-

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Therapeutic Interventions

Figure 31-19. Electromyographic site selection and control

evaluation are performed in preparation for
fitting a myoelectric prosthesis.

sors, while AE amputees learn to isolate the biceps and

triceps. Some myoelectric systems are proportionally controlled; that is, the greater the muscle contraction, the
faster the TD reacts or the greater the grip force produced.
Amputees must learn to use proportional controls appropriately. Greater speed and more force do not translate
into more control.
Amputees who are fit with the myoelectric AE prostheses often need to learn to perform quick co-contractions
of the biceps and triceps to switch control between the
elbow and hand. The prosthesis is in a hand mode except
when co-contraction is used to switch it to the elbow
mode. Like the TD, the elbow is controlled by the biceps
and triceps. If the elbow is held in the same position for a
brief period of time, the elbow automatically locks and the
prosthesis automatically switches back to the hand mode.
Single-site electrodes are available for the individual
who does not have two acceptable control sites or cannot
isolate muscle contractions. In this case, the patient is
taught to create a quick muscle contraction for one prosthetic action and a slow muscle contraction for another.
This same control concept is used for activating powered
wrist rotators.

Switch-Control Training
When myoelectric control sites are not available, other possible control motions (e.g., those that activate an on-off
rocker, button, or pull switch) are considered. These
control motions are usually proximal movements that are
not used for normal ADLs, such as shoulder elevation. As
mentioned earlier, chin nudge switches are occasionally
used. Most of the controls training for this type of
external power is conducted after the individual receives
the prosthesis.

Figure 31-20. During prosthetic training, the amputee learns

to perform a wide range of activities.

Use Training for Conventional or Externally

Powered Prostheses
The study by Lake (65) demonstrated that amputees who
receive prosthetic training show increased spontaneous use
of the prosthesis as well as greater skill and efficiency.
During this phase of training, the OT uses a variety of
techniques. Initially, the therapist teaches the amputee to
perform simple tasks with the prosthesis, and then introduces more difficult bilateral tasks (Fig. 31-20). The OT
has the amputee grasp a variety of objects at different
heights to improve control. Objects are graded in size and
weight. To increase speed, the OT encourages minimal
body movement, accurate TD prepositioning, and use of
surroundings to facilitate task completion. The amputee
learns both active and passive use of the TD. Whenever
possible, the amputee is instructed to relax cable tension
on the conventional prosthesis to avoid fatigue. Similarly,
an amputee using a myoelectric prosthesis needs to relax
the control-site muscles after activation of the myoelectric
components.
During this stage of training, rubber bands are
increasingly added to the VO hook, requiring the user to
generate greater cable tension to operate the TD and
secure an appropriate grip. Once the amputee is able to
produce a pinch force of at least 3 lb (1.35 kg), functional

Chapter 31

tasks are taught, including tying shoes, cutting meat, and

picking up objects. As available pinch force increases, the
amputee also learns to grasp an object without squashing
it. This is particularly important with a myoelectric TD
that can generate high pinch forces.
While the unilateral amputee is typically trained as
an outpatient, the bilateral amputee is best trained as an
inpatient at a rehabilitation facility. Inpatient training
allows more intensive instruction, training, and practice,
effectively shortening the time from receipt of the prosthesis to active regular use. If both prostheses share a common
harness, the patient learns to activate one TD without activating the other.
All ADL issues are addressed, including self-care,
driving, home management, and vocational and leisure
tasks (Fig. 31-21). Videotapes showing other amputees performing various ADL tasks are excellent training tools.
Commercially made TDs are available for recreational
activities such as baseball, gymnastics, weight lifting, and
fishing.
The prosthesis is the primary adaptive device for the
upper-extremity amputee. Other assistive devices should be
kept at a minimum. Adaptive equipment is needed by
some amputees, especially if they use a one-handed
approach. Devices commonly used by the upper-extremity

Upper-Extremity Amputation and Prosthetic Rehabilitation

575

amputee include rocker knives, cutting boards, or scrub

brushes with suction cups to stabilize the object. Unilateral
amputees may require turning knobs affixed to the steering
wheel for turning when driving an automobile.

Bilateral Amputees

Figure 31-21. The individual with upper-extremity loss can

learn to perform activities necessary for
school or work.

Persons with bilateral BE amputation can become completely independent in ADLs (Fig. 31-22). However, learning to do overhead activities is difficult. Individuals with
bilateral amputations may require driving rings, button
hooks, lever-type doorknobs, or ring pulls for zippers to
achieve independence.
In addition to AE prosthetic training, children with
congenital bilateral AE limb deficiencies should learn to
use their feet as they would hands. These amputees frequently require a bidet for toileting. Telephones with a
speaker phone work well for these individuals. Certain
activities (e.g., dressing above the waist or cutting meat) are
extremely challenging. Typically, these individuals, and
amputees with more limb loss, require assistance from
another person at various times during the day for certain
activities such as bathing.
Amputees with bilateral SD or higher limb loss find
it very difficult to don and doff prostheses independently

Figure 31-22. The occupational therapist trains an amputee

to use the prosthesis to perform activities of
daily living (ADLs).

576

Part III

Therapeutic Interventions

(48). They need an attendant at various times to assist

them in performing specific tasks.
Prosthetic use training teaches the upper-extremity
amputee realistic expectations for each prosthetic device.
The length of time prosthetic training takes is extremely
specific to each individual. Some will effectively self-train
while others will require extensive occupational therapy
training.

CONCLUSIONS
Prosthetic restoration and rehabilitation is a rapidly
expanding field. A few basic points are important to
remember. When upper-extremity amputation is necessary,
the procedure needs to be viewed as part of a reconstructive and rehabilitation effort to restore upper-extremity
function. When the surgical and rehabilitation decisions
and interventions focus on the patient as an individual, he
or she is able to achieve maximal function and independence in spite of limb loss.

APPENDIX I. AMPUTEE ASSOCIATIONS

AND PUBLICATIONS
Ability (quarterly magazine)
P.O. Box 5311
Mission Hills, CA 91345
American Amputee Foundation
Tel: (501) 666-2523
Fax: (501) 666-8367
P.O. Box 250218
Hillcrest Station
Little Rock, AR 72225
AMP (quarterly magazine)
12-45 150th Street
Whitestone, NY 11357
Amputee Coalition of America (ACA)
Tel: (888) AMP-KNOW
Fax: (423) 525-7917
C/O Pam Trentham
900 E. Hill Ave, Suite 285
Knoxville, TN 37915-2568
(Annual spring conference and many other services)
National Amputation Foundation
Tel: (516) 887-3600
Fax: (516) 887-3667
73 Church Street
Malvern, NY 11565

Chapter 31

National Amputee Fund

Tel: (800) 770-5090
6147 University Avenue
San Diego, CA 92115-5796
(Provide assistance with finding prostheses)
United Amputee Services Association, Inc.
Tel: (407) 395-1701
855 S. Federal Highway, Suite 212
Boca Raton, FL 33432
(Pamphlet: A Survivors Guide for the Recent
Amputee)

APPENDIX II. UPPER-EXTREMITY PROSTHETIC

MANUFACTURERS, DISTRIBUTORS, AND
RESEARCH CENTERS
In United States
Fillauer, Inc.
Tel: (800) 251-6398 or (615) 624-0946
Fax: (615) 622-7836
P.O. Box 5189
2710 Amnicola Highway
Chattanooga, TN 37406
(Manufacturer/distributor prosthetic parts)
Health Related Products/Realastic
Tel: (800) 845-4566
Fax: (864) 229-1230
P.O. Box 3465
1704 Mathis Road
Greenwood, SC 29649
(Standard and custom polyvinyl chloride prosthetic gloves,
silicone digits)
Hosmer Dorrance Corporation
(Fillauer Subsidiary)
Tel: (800) 827-0070 or (408) 538-7748
Fax: (408) 379-5263
561 Division Street
PO Box 37
Campbell, CA 95008
(Myoelectric and conventional components;
NY Electric Elbow; NY Prehension Actuator,
NU-VA Synergistic Prehensor)
Liberty Technology
Tel: (508) 435-9061
Fax: (508) 435-8369
71 Frankland Road
Hopkinton, MA 01748
(Myoelectric components by developer
T. Wally Williams; Boston Elbow; distributor of all pediatric electronic components worldwide)

Upper-Extremity Amputation and Prosthetic Rehabilitation

577

Life-Like Laboratories
2718 Hollendale Lane, Suite 400
Dallas, TX 75234
(Horst Bruckner, president; company makes custom
silicone gloves, patented procedures, written articles)
Motion Control
(Fillauer Subsidiary)
Tel: (800) 621-3347
Fax: (801) 972-9072
3385 West 1820 South
Salt Lake City, UT 84104
(Harold Sears, PhD, vice-president and general manager;
Utah Elbow, BE procontroller)
Otto Bock Orthopedic Industry
Tel: (800) 328-4058
Fax: (612) 519-6153
3000 Xenium Lane North
Minneapolis, MN 55441
(Originated in Germany, Otto Bock Hand, Greifer, Wrist
Rotator, myoelectric components)
Pilot Hand Prostheses
Tel: (800) 441-HAND
Fax: (212) 489-7808
331 W. 57th Street, #109
New York, NY 10019
(Custom silicone gloves)
The Institute for Rehabilitation & Research
(TIRR) Amputee Center
Tel: (713) 797-5237
Fax: (713) 797-5904
1333 Moursund
Houston, TX 77030
(Diane Atkins-Jones, OTR, editor of Comprehensive Management of Upper-Limb Amputee, New York: Springer, 1989)
Therapeutic Recreation Systems (TRS)
Tel: (800) 279-1865
Fax: (303) 444-5372
2450 Central, Suite D
Boulder, CO 80301
(Bob Radocy, president; BE amputee developer of VC
Adept and Grip hooks and numerous sports terminal
devices, several videotapes for sale including one of sports)
United States Manufacturing Co.
Tel: (818) 796-0477
Fax: (818) 440-9533
P.O. Box 5030
180 N. San Gabriel Boulevard
Pasadena, CA 91107-0030
(Manufacturer quick disconnect wrist, mechanical elbows,
books)

578

Part III

Therapeutic Interventions

VA Rehabilitation Research and

Development Service
Tel: (410) 962-1800
Fax: (410) 962-9670
E-mail: pubs@ballt-rehab.med.va.gov
103 South Gay Street
Baltimore, MD 21202-4051
(Myoelectric components: synergistic prehensor and
elbow, puts out yearly research and development progress
reports)

Outside United States

Centri Gummifabrik AB
Tel: 011-46-8580-31 165
Fax: 011-46-8580-81 128
Lidvagen 37S-17540
Jrflla, Sweden
(Powered hands, gloves, upper-extremity prosthetic
components)
Hugh MacMillan Medical Centre
Tel: (416) 425-6220
Fax: (416) 425-6591
350 Rumsey Road
Toronto, ON, Canada M4G 1R8
Hugh Steeper (Roehampton) Ltd.
Tel: (01) 788-8165
237-239 Roehampton Lane
London SW15 4LB, England
(Steeper Hand, Systemteknik Hand,
Servo Hand, wrist units, Gripper powered hook)
Loth Fabenim
Tel: 011-31-3073-25 06
Fax: 011-31-3071-10 45
Netherlands
Orthopadie Brillinger
Tel: 011-49-7071-41 04 0
Fax: 011-49-7071-41 04 50
Germany
Otto Bock Orthopedic Industry
Tel: (800) 665-3327 or (905) 829-2080
Fax: (905) 829-1811
2897 Brighton Road
Oakville, ON, Canada L6H 5S3
Otto Bock Orthopadische Industrie KG
Tel: 011-49-055-27 8480
Fax: 011-49-055-27 72330
Postfach 1260
37105 Duderstadt, Germany

Systemteknik AB
Prosthetics and Orthotics Group
Tel: 011-46-876-70370
Vasavgen 76 S-18141
Liding, Sweden
David Trainer
Anaplastologist
Germany
University of New Brunswick
Prosthetics Research Centre Institute
of Biomedical Engineering
Tel: (506) 453-4966 or 454-8283
Fax: (506) 452-1040
180 Woodbridge Street
Fredericton, NB, Canada E3B 4R3
(Annual myoelectric controls course and symposium on
their system in August)
Variety Ability Systems (VASI)
Tel: (416) 698-1415 or (800) 891-4514
Fax: (416) 698-5860
3701 Danforth Avenue
Scarborough (Toronto), ON, Canada M1N 2G2
(Developer of Cookie Crusher childrens myoelectric
hand, hands, elbow, gloves)

APPENDIX III. UPPER-EXTREMITY AMPUTEE

INFORMATION RESOURCES
American Academy of Orthotists and Prosthetics
Tel: (703) 836-7118
Fax: (703) 836-0838
1650 King Street, Suite 500
Alexandria, VA 22314
(Journal of Prosthetics and Orthotics, Orthotics and Prosthetics
Almanac)
American Anaplastology Association
Tel: (415) 221-9775
493 Eighth Avenue
San Francisco, CA 94118
(cosmetic gloves, journal, annual conferences, international
membership)
American Occupational Therapy Association
(AOTA)
Tel: (301) 652-AOTA X288
Fax: (301) 652-7711
4720 Montgomery Lane
P.O. Box 31220
Bethesda, MD 20824-1220
(Video for sale/rent: The Use of Upper Extremity
Prostheses by Art Heinze, OTR)

Chapter 31

Area Child Amputee Center

Mary Free Bed Hospital and Rehabilitation
Center
Tel: (616) 454-7988
Fax: (616) 454-3939
E-mail: amputee@mf brc.com
235 Wealthy Street, SE
Grand Rapids, MI 49503
(Pamphlets for sale: Children With Limb
Loss Handbooks for families and teachers;
Children with Hand Differences: A Guide
to Familiesalso available in Spanish)
Association of Childrens Prosthetic-Orthotic
Clinics (ACPOC)
Tel: (847) 698-1637
Fax: (847) 823-0536
E-mail: king@aaos.org
6300 N. River Road, Suite 727
Rosemont, IL 60018-4226
(Annual spring conference and quarterly news bulletin)
Gillette Childrens Hospital
Medical Media
Tel: (612) 229-3800
Fax: (612) 229-3833
200 East University Avenue
St. Paul, MN 55101
(Videos: Upper Limb Options, Did You Know . . . ,
The Team Approach, Active Closing Terminal Device)
International Society for Prosthetics and
Orthotics (ISPO)
Tel: 011-45-31 20 72 60
Fax: 011-45-31 20 75 01
ISPO Secretariat
Borgervaenget 5
2100 Copenhagen 0
Denmark
(International conferences every 3 years in
different countries: 1998, 2001, 2004 also publishes
Prosthetics and Orthotics International )
Northwestern University Medical School
Orthotic/Prosthetic Center
Tel: (312) 908-8006
Fax: (312) 503-6803
Prosthetic-Orthotics Education
345 East Superior Street
Chicago, IL 60611-4496
(Annual review courses)
Prosthetics and Orthotics Engineering
(monthly newsletter)
Lippincott-Raven Publishers
Tel: (800) 777-2295

Upper-Extremity Amputation and Prosthetic Rehabilitation

579

Fax: (301) 824-7390

P.O. Box 1600
Hagerstown, MD 21741-9932

University Hospital 1G225

1500 E. Medical Center Drive
Ann Arbor, MI 48109-0046
( Video for sale: Tri-Membral Congenital
Limb DeficiencyThe Ultimate Challenge: Pregnancy
and Child-Care)

Rehabilitation Institute of Chicago

Education and Training Material
Tel: (312) 908-2859
Fax: (312) 908-4451
345 East Superior, Room 1610
Chicago, IL 60611
(Video and guide for sale: Upper-Limb
Prosthetic Options for Kids: Below-Elbow)
University of Michigan Medical Center
Occupational Therapy Division
Department of Physical Medicine and
Rehabilitation
Tel: (313) 936-7160
Fax: (313) 936-7016

VA Rehabilitation Research and Development

Service
Tel: (410) 962-1800
Fax: (410) 962-9670
E-mail: pubs@ballt-rehab.med.va.gov
103 South Gay Street
Baltimore, MD 21202-4051
(Journal of Rehabilitation Research and Development and annual
progress report)

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